Provider Demographics
NPI:1104812403
Name:ISHERWOOD, JEAN T (WHNP-BC)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:T
Last Name:ISHERWOOD
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:T
Other - Last Name:DOBEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 W MAIN ST STE 201&209
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2507
Practice Address - Country:US
Practice Address - Phone:803-785-4777
Practice Address - Fax:803-358-6240
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3671363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS94833Medicare UPIN
PA034111Medicare ID - Type Unspecified